Ezekiel Stephan Synopsis
Mr. Anthony F. Stephan, As promised, Please see the files below for the most obvious issues with your son's case in short form.
At Trial:
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The first indication that something was really wrong with this case was when the former Chief Medical Examiner for Alberta, Dr. Anny Sauvageau, testified in opposition to the Medical Examiner who performed the autopsy, Dr. Bamidele Adeagbo.
Her report and testimony decimated her former employees assertions and proved a lack of evidence for meningitis being a cause of death. Dr. Sauvageau also identified an X-Ray from Ezekiel's visit to the Cardston Hospital that was not included in the defenses files. |
Credit SHAUGHN BUTTS
Credit SHAUGHN BUTTS
Dr. Anny Sauvageau Former Chief Medical Examiner - Alberta |
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The inconsistencies that led to the investigation being performed, after the failure of the appeal, have uncovered a significant numbers of crimes that were committed by medical staff and the police.
We have now recovered 138 missing pages of medical documentation. We are currently being denied access to information requests with the RCMP. Based on what we know, we estimate that there are over 300 pages of medical evidence still being withheld. |
Anny Sauvageau Testimony / Reports
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Here is what we know and how we came to the conclusions we have thus far.
Upon looking deeper into the file we recognized that the Cardston X-Ray had been removed from RCMP production orders as well as disclosure from the medical examiners office. These files were the basis of the Crown prosecutors evidence used to wrongfully prosecute your son and daughter in law. This begs the question as to why this X-Ray was removed from disclosure. |
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Cardston Hospital Files |
Cardston Hospital x-ray taken shortly after arrival
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The x-ray that was removed showed two things of exculpatory significance.
First was the fact that his stomach was holding a large amount of air. This is significant because when a person dies their gastric sphincters relax and the contents of the stomach exit into the esophagus, mouth, and nose. Medical professionals who testified in the case would indicate that Ezekiel was brain dead on arrival at the Cardston Hospital. This was clearly not the case as the body requires brainstem activity to maintain the closed gastric sphincters that retained the pressure in his stomach. |
Trachea tear identified in the Cardston Hospital X-Ray
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Second was the fact that a tear in the trachea is evident in the same x-ray. Upon further investigation we found autopsy photos where a deep gouge in the pleura covering Ezekiel's spinal column is present directly under the tear in the trachea.
This tear would result in aspirant, that was identified in the 911 call transcripts, leaking into Ezekiel's thoracic cavity and resulting in a massive lung infection that the medical examiner would list as one of the causes of death. |
Deep gouge directly under the trachea tear that was identified on the Cardston x-ray
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Further investigation would uncover perjury and falsification of documents by two Doctors in Cardston who administered to Ezekiel
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911 call transcripts discussing fluids in Ezekiel's airway
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We were able to discover evidence that both Dr. Alexander Cunningham and Dr. Lloyd Clarke perjured themselves in what appears to be an effort to distance themselves from the botched intubation procedure.
The events leading to the trachea tear in 18 month old Ezekiel were caused by an undersized intubation tube being inserted with enough force to not only tear his trachea but to also leave a deep gouge in the pleura below the tracheal tear. Undersized Intubation tubes can turn in the trachea resulting in the tip digging into the tissue and a tearing or puncturing it. Medical records show that Ezekiel was Intubated / reintubated 4 times in less than 3 hours. Both doctors would deny in testimony having anything to do with the procedure in spite of hospital records that placed Dr. Cunningham as the medical professional who performed the intubation and a detailed description of the procedure by Dr. Lloyd Clarke. No attempt to repair the damaged trachea can be found on record or in court transcripts. Interviews with family members who were present after the injury took place, present no indication of knowledge of attempts to fix the fatal injury. This would suggest that the medical professionals were actively attempting to cover up the medical error that took place in Cardston Hospital. Ezekiel was quickly passed off to the next group of doctors at the Lethbridge hospital (Chinook Regional Hospital) Click Here for the Cardston Hospital Synopsis |
Dr. Lloyd Clarke - Cardston Alberta Hospital
Dr. Alexander Cunningham - Cardston Alberta Hospital
Chinook Regional Hospital
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Cardston Hospital to Chinook Regional Hospital
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From the Cardston Hospital Ezekiel was transferred to the Chinook regional Hospital in Lethbridge Alberta.
The events that would take place here are such that I have difficulty finding words to accurately describe them. The events that took place in Lethbridge Alberta took our team of four investigators more than 60 days to uncover as a result of the fact that all but three pages of medical records were destroyed. We were forced to rely on the notes of the medical doctor who was in contact through a RAPID call, conflicting testimony, as well as the contradictory notes of the stars team. The STARS notes were written in flight between the Chinook Regional Hospital and the Alberta Children's Hospital. The STARS team notes included events that happened after the flight was completed. |
Medical note from Dr. Jack Regehr declaring no involvement in what took place
Dr. Jack Regehr - Chinook Regional Hospital emergency room supervisor
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Inconsistencies in the STARS team notes led the investigative team to believe that they had been falsified to hide critical medical information about Ezekiel's care and condition during his stay in the Chinook Regional Hospital.
What we know: Between 00:31 and 00:45 on the 14th of Mar 2012 a currently unidentified medical professional administered a drug which medical testimony would indicate is used to keep patients who are waking up from pulling out their IVs and tubes. Medical notes from Dr. Burkholder who was on the phone with the STARS team would indicate that Ezekiel was breathing on his own. The notes indicated that doctors were aware that Ezekiel had an electrolyte imbalance that would make the drug he was given extremely dangerous to him. The notes along with testimony, show that he suffered a second cardiac arrest immediately after the drug was given to him. Doctors in Lethbridge ignored the medical warnings provided by the drug manufacturer and the critical lab data from the Cardston Hospital. This resulted in a second cardiac arrest and a catastrophic level of brain damage. It was recorded after the drug was given to Ezekiel, that an ongoing cardiac arrest would take place for almost two hours. This was likely the point where medical staff would have recognized that Ezekiel had a heart condition associated with Prolong QT Syndrome. ECG strips in Cardston showed evidence of prolonged QT and lab reports showed a potassium imbalance that should have alerted attending medical professionals to the critical issue at hand. There is no evidence to suggest that anyone in Cardston had a clue about what was actually going on. There is an hour and 15 minutes of medical logs and files that are missing from the Chinook Regional Hospital. During this time critical care was provided and we have no detailed reports of it whatsoever. We estimate that at least 30 pages of medical records were destroyed from this location alone. The medical records that are missing or destroyed include: -ECG strips -Medical logs - Medications logs -vital statistics logs -Lab reports Click here for the full Chinook Regional Hospital Synopsis |
Dr. Shauna Burkholder - Alberta Children's Hospital
Dr. Shauna Burkholder's notes showing that medical staff were aware of Ezekiel's potassium imbalance, that he was breathing on his own, and that he was given ROC which was followed by a severe cardiac arrest.
Last medical log before arriving at the Chinook regional Hospital. Final time is 00:25
Confirmation letter from the information officer at Chinook regional Hospital that no lab reports or medical logs exist other than the radiology report and the note saying that Dr. Jack Regehr was not involved.
STARS Ambulance Records detailing lab results from Chinook Regional Hospital that are either missing or have been destroyed along with an estimated 30 more pages of medical files.
medical logs resumed at 0140. An hour and 15 minutes of medical logs have been confirmed missing by the information officer at the Chinook Regional Hospital
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Chinook Regional Hospital to STARS Ambulance Transport to Alberta Children's Hospital
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From the Chinooks Regional Hospital, Ezekiel was transferred by STARS Ambulance, to Alberta Children's Hospital.
What Happened: Cardio records show that Ezekiel was not stabilized when transport to the Alberta Children's Hospital was initiated and medical charting resumed. At this time he was experiencing a cardiac arrest. After entering the air ambulance and while all other medical staff were no longer present, the Alberta Children's Hospital team administered three excessive doses, in quick succession, of the same drug that had resulted in the in-hospital cardiac arrest less than an hour before. The notes provided by the stars transport team that indicated the outcome of future events would indicate that the cause of the Chinook regional Hospital cardiac arrest was the result of physicians attempting to wean Ezekiel off epinephrine during transport. This brings into question the medical professionals motivation for putting this information on the record as it would be the absolute worse thing to do to and unstable patient during transport and is contrary to sound medical practice. This statement is also contradictory to other medical notes surrounding Ezekiel's visit to the Chinook Regional Hospital. In our opinion the most likely reason why this statement was put into the notes was to mask the fact that Ezekiel was likely deemed past saving after the in-hospital cardiac arrest and the three doses of ROC were administered to end his suffering. |
STARS Ambulance Transport Log show the administration of three large doses of ROC even after the first dose resulted in a cardiac arrest
Dr. Sandu, the attending physician on the STARS transport team, explaining the Chinook Regional Hospital Cardiac Arrest in her notes and indicating that they were attempting to wean him off Epi during transport...
Dr. Naminder Sandhu - Alberta Children's Hospital
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Alberta Children's Hospital - Medical coverup / perjury / falsification of documents
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Ezekiel went from the STARS air ambulance to the Alberta Children's Hospital.
What we know: Ezekiel was taken directly to the CT scanner for a head scan. Medical staff would find nothing on the CT scan to indicate meningitis. DNA Banking to test for prolonged QT took place but tests were either abandoned or the results were destroyed. ECG confirmed Prolonged T wave. |
Note from Dr. Jon Gamble discussing the lack of evidence for meningitis and the need to look for alternatives
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Medical Records show that Alberta Children's Hospital staff told outside doctors and social workers of multiple cardiac arrests and lack of evidence to support meningitis that would result in cardiac arrest.
Police records would show that the Alberta Children's Hospital staff told police that examinations showed obvious signs of meningitis causing Ezekiel's death. There is no evidence in the medical files of tests being done that are specific to meningitis. There is evidence in the medical file that doctors did not do any tests specific to meningitis. |
SSRT report where the social worker describes a statement from Dr. Catherine Ross where she indicates that there is no clear reason for the cardiac arrest based on the meningitis claim. Lumbar puncture was never completed to test for meningitis
medical investigators summary showing awareness that Ezekiel went for up to 20 minutes without proper oxygen as a result of inadequately stocked ambulances, echo cardiogram shows that the heart is not functioning properly but no other and organ sequelae is noted (issue is related to the heart). Drs. approve organ donation in spite of claims that Ezekiel has an extremely contagious disease
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At about 4 o'clock on 14 March 2012 in the morning Ezekiel developed a DI as a result of oxygen deprivation permanently damaging the hypothalamus and pituitary gland.
Mean Arterial Pressure calculations show 3+ hours before the CT scan was performed where Ezekiel was without proper oxygen getting to his brain. Mean arterial pressure calculations show numerous unreported cardiac arrests in hospital that appear to coincide with changes to electrolyte replacements (urine replacements) administered by hospital staff. |
Mean Arterial Pressure Calculations
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Two x-rays were taken. One was to investigate the air leak (Tracheal Puncture that resulted in Ezekiel's thoracic cavity filling with air instead of his lungs). The other was to check the position medical equipment.
A battery of microbe biological tests were performed which all came back negative. The quarantine on Ezekiel's room was removed as it was determined that Ezekiel did not have a contagious disease. An echocardiogram was performed and showed that Ezekiel's heart was working at approximately 18%. |
Radiology report for air leak investigation
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Medical Staff falsified reports the police were requesting.
This happened repeatedly. The most common lie was that physical exams showed obvious signs of bacterial meningitis. No physical tests for meningitis were performed in hospital. |
Dr. John Gamble's death summary where he claims that Scant gram-negative bacilli grew in the lab for the CFS and lung. This death summary was a key piece of evidence used in prosecuting the Stephans.
the lab report for the CFS showing no growth at all. This report proves that key portions of the death summary were falsified by Dr. John Gamble.
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An ECG was performed. Charts from the ECG were found in the 138 pages of missing disclosure.
The test strip from the ECG confirmed borderline prolong QT. The doctor performing the ECG raised the concern of not having previous ECG strips to work from. Medical staff changed Ezekiel's electrolyte replacements putting him into a's state before hypokalemic before the ECG. Even in this state Ezekiel had a T wave of 456 ms. Note: Ezekiel was hyperkalemic at the time the ROC was administered at the Chinook Regional Hospital. Rocuronium bromide (ROC) is known to lengthen the T wave and is not recommended for people suffering from an electrolyte imbalance for this reason. reducing his potassium below the safe range is a strong indication that medical staff were aware of the potassium interaction that was the most likely cause of Ezekiel's cardiac arrest. |
ECG test strips withheld from disclosure
electrocardiogram confirming that Ezekiel had a prolonged QTc of 456 ms
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The parents and authorities were not notified of the potassium interaction.
Note: Ezekiel tested positive for hyperkalemia with a potassium level of 6.4 with slightly hemolyzed blood when he was first admitted. The father David Stephan had mentioned repeatedly that Ezekiel had consumed an electrolyte drink about three hours before going into cardiac arrest.
Medical staff showed signs that they were aware of the issue with the potassium and prolonged QT.
If Ezekiel's condition was in fact precipitated by the use of a tainted batch of electrolyte drink mix the doctors inaction placed the lives of thousands of consumers at risk.
Note: Ezekiel tested positive for hyperkalemia with a potassium level of 6.4 with slightly hemolyzed blood when he was first admitted. The father David Stephan had mentioned repeatedly that Ezekiel had consumed an electrolyte drink about three hours before going into cardiac arrest.
Medical staff showed signs that they were aware of the issue with the potassium and prolonged QT.
If Ezekiel's condition was in fact precipitated by the use of a tainted batch of electrolyte drink mix the doctors inaction placed the lives of thousands of consumers at risk.
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CT scans showed Hypoxic injury associated with the slow oxygen deprivation caused by the medical errors.
CT scans shows no tonsillar herniation. This would have been there if he had meningitis that caused brain stem compression. 
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Radiology report that indicated that Ezekiel suffered from hypoxic injury with no brainstem compression (tonsillar herniation). This conflicted with doctor's reports to police and testimony that indicated he died from brainstem compression as a result of meningitis
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We received 623 pages of medical documentation and a cover letter from the Alberta Children's Hospital.
You received in disclosure 453 pages of medical documentation from the Alberta Children's Hospital. Files that were withheld from disclosure contained numerous instances of exculpatory evidence that should have been available at trial. There is strong evidence to suggest that someone with inside knowledge at the Alberta Children's Hospital influenced police disclosures to exclude files containing vital statistics, charts and contradictory evidence. There is evidence proving ongoing discussions between hospital staff and the Medical Examiner's Office during the autopsy. Summary There is a plethora of information I could be added to this section of the synopsis. In the interest of time we are moving on to the next time frame from here. There is clear evidence that the medical professionals at the Alberta Children's Hospital were key in creating the false narrative that Ezekiel died of bacterial meningitis. Medical doctors would repeatedly ignore the information presented to them by the lower medical professions. Lab reports, radiologists, and EMS were repeatedly second-guessed at the cost of Ezekiel's life. |
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-Medical Examiner Dr.Bamidele Adeagbo - X-Ray removed from disclosure, discovery of numerous perjury's, forgeries and falsified documents used in court.
 Bamidele Adeagbo
The X-Ray being removed from the file pointed us down a path where we have now acquired evidence that Bamidele perjured himself repeatedly during the trial.
Between the Perjury and the falsification of evidence to be used in court, Bamidele could potentially serve over 25 years in prison. One example of this was his misrepresentation of lab results during testimony. It is also evident that he was involved in the falsification of lab reports as well as the autopsy report. Of particular interest is the fact that the former chief medical examiner was directed by the court not to refer to trial transcript that contained some of the more obvious perjury's. We have included two detailed examples with evidence Click Here for more detailed information. Warning! Graphic content |
CFS lab results showing no growth in cultures
Testimony of the medical examiner testifying of growth in the CFS culture. This is clear evidence that Dr. Bamidele Adeagbo perjured himself. This was a common theme throughout his testimony and contact with this file
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This led us to focus on the X-Ray that was removed from disclosure in both the Medical Examiners file and the RCMP production orders.
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the medical examiners comments in the autopsy report regarding Ezekiel's trachea.
after receiving a negative lab report showing no bacterial meningitis the medical examiner called the lab and instructed them to find the bacteria. This would lead to an adjusted report and a nonclinical lab test that would be used as a key piece of evidence but would never be produced
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RCMP - Threatened witnesses / Withheld evidence / Refusal to investigate crimes
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RCMP would play a key role in fabricating the case.
RCMP Motive would extend almost 30 years. Click here to view the RCMP files Evidence would surface that they selectively chose evidence favorable to the case while not collecting evidence that was damaging to the case. Witnesses would indicate that they felt threatened. RCMP files contained evidence that they were building cases on at least one witness who would not give a statement. We have contacted the RCMP with respect to crimes committed during the case. The RCMP have refused to investigate evidence contrary to their case. RCMP were sent a full copy of all the recovered records. RCMP Sgt Kelly McCoy indicated on a recorded call that they were the same documents they had turned over to the crown. The disclosure file contained an index of what the RCMP had obtained and it did not include the missing evidence. Production orders collected by the RCMP would be turned over the defense with pages missing. RCMP are currently ignoring information requests needed for evidence that was going to be presented to the Supreme Court of Canada. Documents that were critical to the defenses case were identified in FOIP requests after the trial. Some of these documents were missing from files that were numbered. The numbered pages that were missing also correlated with the missing files. There is currently and outstanding ATI request from Dec 21 of 2017 that has yet to be answered. |
Three pages above show the number of pages collected by the RCMP vs the pages collected by the investigative team from the ACH records department
Unanswered request for information dating back to 2017
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Court proceedings - Misleading the court / perjury / falsification of documents
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Much of this has been covered in previous sections. Two brief examples of the ongoing attitude shown throughout the trial are:
-Dr. Shauna Burkholder avoiding answering questions about the second cardiac arrest that took place in the Chinook Regional Hospital. -The court directing key defense witness to censor evidence from the jury. There are approximately 3500 pages of this kind of disturbing content. |
Dr. Shauna Burkholder dodging questions in court transcripts.
Dr. Shauna Burkholder's own hand written note detailing the beginning of the Cardiac Arrest that took place during the transport between Cardston and the Alberta Children's Hospital
Dr. Anny Sauvageau in testimony discussing being censored by the court
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Canadian Media - Lies / misinformation / reports that were opposite court evidence
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The Canadian media are relying heavily on recorded conversations with police where David and Collet had been awake for almost 48 hours and had been talking to medical doctors for at least 24 hours prior. Both parents recite repeatedly comments made in doctors reports that would require a medical background to fully understand. When taken in context, their conversations at this time appear out of place and beyond their level of comprehension.
Shortly after police engaged Collet and David, two local reporters approached the RCMP with information about the case. One claimed he had knowledge of medical information. The other claimed that David's family business had a guilty verdict against it for selling natural therapies. |
The media were pushing the charges forward with false allegations even before the trial.
News media reporting information that conflicts with what the reporters told police.
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What was testified of in Court
ER nurse who visited Ezekiel the day before he entered the hospital found no obvious symptoms.
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What the media said
Bill Kaufmann with The Calgary Herald wrote that the ER nurse pleaded for them to allow him to receive proper care
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A paramedic who saw him at church along with over 300 other people said he was playing two days before he died.
His Grandfather saw him the night before he arrested and said he was crawling around
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Canadian Media reported he lay ill for weeks
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Parents testify that Ezekiel was taken out of his car seat because he was uncomfortable and might have the flu.
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Media report he could not get into his car seat because he was too stiff with meningitis.
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Stephan's make electrolyte drink from maple syrup and water instead of gatorade
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Huff post alleges they treated their son with maple syrup
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Unaired video shows prosecutors explaining that the Stephans were not found responsible for Ezekiel's Death
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Media report that the Stephans were found guilty in their sons death
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Summary
In looking at the file with all of the evidence present there is only one conclusion that makes sense.
The reporter who approached the police with the same medical narrative that the Alberta Children's Hospital doctors concocted, could not have gotten that information unless someone at the Alberta Children's Hospital was talking to him or her. It could have easily been either one of the reporters who pushed the meningitis narrative. Once the media go down a road like this they are not likely to turn back.
The RCMP would not have known what was in the files that they cherry picked unless they had assistance from inside the Alberta Children's Hospital
The medical examiner would not have had the narrative to pursue without contacts within the Alberta Children's Hospital
There is evidence of the first falsified documents coming from the medical staff at the Alberta Children's Hospital and the ease with which the ACH doctors navigated the situation is indicative of a group of people are not new to this kind of illegal behavior.
Every time a major event took place in Ezekiel's medical care and a doctor from the ACH was present, medical logs and charts would disappear.
In Cardston when the trachea puncture took place and a cover up was attempted there were multiple records that did not line up. In our opinion the medical doctors from Cardston did not have the experience or level of intelligence it would take to successfully do what was done to your son and his wife.
There would have had to have been some level of collusion between the medical doctors at the various hospitals in an effort to keep their story straight.
There is strong evidence that doctors at the Alberta Children's Hospital were aware of the heart defect and the air leak but chose not to report either.
If you want to find out who is at the centre of this conspiracy to cover up the medical error and cast blame on your son and his wife, you will need to look to the Alberta Children's Hospital.
We are nearing completion on the file and have enjoyed working with you and your family. We will be in contact over the next few weeks. Please let me know if there's anything we have missed or if there are grammar errors on the page as we rushed to get this done over the weekend.
Best regards
The Gordon Rock Investigative Team
The reporter who approached the police with the same medical narrative that the Alberta Children's Hospital doctors concocted, could not have gotten that information unless someone at the Alberta Children's Hospital was talking to him or her. It could have easily been either one of the reporters who pushed the meningitis narrative. Once the media go down a road like this they are not likely to turn back.
The RCMP would not have known what was in the files that they cherry picked unless they had assistance from inside the Alberta Children's Hospital
The medical examiner would not have had the narrative to pursue without contacts within the Alberta Children's Hospital
There is evidence of the first falsified documents coming from the medical staff at the Alberta Children's Hospital and the ease with which the ACH doctors navigated the situation is indicative of a group of people are not new to this kind of illegal behavior.
Every time a major event took place in Ezekiel's medical care and a doctor from the ACH was present, medical logs and charts would disappear.
In Cardston when the trachea puncture took place and a cover up was attempted there were multiple records that did not line up. In our opinion the medical doctors from Cardston did not have the experience or level of intelligence it would take to successfully do what was done to your son and his wife.
There would have had to have been some level of collusion between the medical doctors at the various hospitals in an effort to keep their story straight.
There is strong evidence that doctors at the Alberta Children's Hospital were aware of the heart defect and the air leak but chose not to report either.
If you want to find out who is at the centre of this conspiracy to cover up the medical error and cast blame on your son and his wife, you will need to look to the Alberta Children's Hospital.
We are nearing completion on the file and have enjoyed working with you and your family. We will be in contact over the next few weeks. Please let me know if there's anything we have missed or if there are grammar errors on the page as we rushed to get this done over the weekend.
Best regards
The Gordon Rock Investigative Team